Causes of Poor BP control Rates

Transcription

1 Goals Of Hypertension Management in Clinical Practice World Hypertension League (WHL) Meeting Adel E. Berbari, MD, FAHA, FACP Professor of Medicine and Physiology Head, Division of Hypertension and Vascular Medicine American University of Beirut- Medical Center Venue: Fairmont Heliopolis Hotel, Cairo- Egypt Date : Tuesday- April 8, 28 Causes of Poor BP control Rates Role of Physician /Health Care Provider 1. Lack of appreciation of definition of hypertension and importance of cardiovascular risk factors. 2. Excessive reliance on monotherapy 3. Therapeutic inertia Reluctance to increase drug dose or to add additional antihypertensive agents. Role of Patient 1. Non adherence /non compliance with prescribed medications 2. Lack of persistence Continuation of use of medications only for a specified time period Impact of antihypertensive regimen 1. Complexity of treatment 2. Drug associated side effects 3. Drug cost 1

2 Risk Relative /75 135/85 155/95 175/5 195/115 mm Hg mm Hg mm Hg mm Hg mm Hg Increasing increments of blood pressure are associated with increasing risk of cardiovascular mortality. Cumulative In ncidence (% SBP <12/< / /85-89 DBP BP Category Optimal Normal High Normal Impact of High Normal BP on Risk of CV Event Cumulative yr Incidence of First Cardiovascular Event According to BP Category at baseline (Framingham Heart Study) 2

3 Age Related Blood Pressure Changes 16 g) d Pressure (mmh Bloo Systolic Diastolic Males Females Age in years In Framingham Heart Study Gradual shift from DBP to SBP as cardiovascular risk predictors In patients younger than 5 years, DBP major predictor In patients 5 59 years, SBP/DBP, equal predictor In patients 6 years and older, coronary heart disease: Positive Correlation with SBP Inverse Relation with DBP 3

4 DBP at Baseline Risk of Death in Control (Untreated) Patients with Systolic (SBP) at Baseline and Fixed Levels of Diastolic (DBP) in Elderly (7 7yrs) Patients with Isolated Systolic Hypertension Ratio SBP DBP PP Hazard 1.5 Blood Pressure (mmhg) Adjusted hazard ratios for combined coronary heart disease and cerebrovascular disease (CHD+CVD) events, SBP:Systolic Blood Pressure, DBP; Diastolic Blood Pressure; PP : Pulse Pressure 4

5 Systolic hypertension recently recognized as more important than diastolic hypertension: - Cardiovascular risk factor - Therapeutic decision making in older subjects - Poor hypertension control in 7 % of treated patients due to inability of reaching goal SBP < 14 mmhg CHD RISK (%) Impact of Serum Chelesterol Levels on Risk of Heart Attacks Hypertension Serum Cholesterol (mg/dl) SBP LOW RISK No Smoking Normal Glucose Tolerance No EKG-LVH Data from Framingham study 5

6 Hypertension CHD RISK % Impact of Serum Cholesterol Levels on Risk of Heart Attacks Systolic Blood Pressure HIGH RISK Smoking Glucose Intolerance EKG-LVH Serum cholesterol (mg/dl) Data from Framingham study Age 4 Years SBP 18 mmhg Age 6 Years SBP 12 mmhg Similar Cardiovascular Risk 6

7 Determinants of CV Events risk during 2 years of successful antihypertensive treatment in middle aged subjects (modified from Alderman) Rates pe er persons /ye ear Age >5 PP>6 Smoking Cholesterol DM LVH Heart Stroke > 6.34 Attack Provider Educational Strategies to improve compliance Combinational approach to improve compliance Affective Behavioural Parthan et al. Exp Rev Pharmacoeconomics Outcomes Res 26;6:

8 ACCOMPLISH: Exceptional ControlRates with Initial Combination Therapy Control rate (%) Achieved Control Rates N=11, N=3, N=8, N=1, All Nordic U.S. African American Baseline Control Rates Incidence of serious hypotensive episodes 1.8 % in 12.6 patients Jamerson ASH 27 Multiple Antihypertensive Agents are Needed to Reach BP Goal Trial (SBP achieved) ASCOT-BPLA (136.9 mmhg) ALLHAT (138 mmhg) IDNT (138 mmhg) RENAAL (141 mmhg) UKPDS (144 mmhg) ABCD (132 mmhg) MDRD (132 mmhg) HOT (138 mmhg) AASK (128 mmhg) Average no. of antihypertensive medications Reproduced from Am J Med 116(5A), Bakris et al. pp. 3S 8. Copyright 24, with permission from Elsevier; Dahlöf et al. Lancet 25;366:

9 Advantages of Fixed Versus Free Combinations of Two Antihypertensive Drugs Simplicity it of treatment Fixed Free + Compliance + Efficacy + + Tolerability +* Price + Flexibility + *Lower doses generally used in fixed-dose combinations + = potential advantage Increased Persistence with Fixed-dose dose Combinations Compared with Individual Component-based Therapy Fixed-dose combination (Valsartan/HCTZ) (n=8,15) 54% p<.1 Free combination (Valsartan + HCTZ) (n=561) 19% % 2% 4% 6% 8% Persistence (defined as patients remaining on treatment for a duration of 12 months) Jackson et al. Value Health Suppl 26;9:A363 9

10 Blood Pressure Goals Non diabetic Diabetic Chronic kidney disease (UAE 1G/D) Coronary artery disease < 14/9 (or less if tolerated/ achievable < 13/8 < 125/75 Early/ aggressive Antihypertensive treatment. Delay Prevent Reverse BP related Target organ damage Protection Future Morbidity Mortality Effects of early/aggressive antihypertensive treatment

11 Risk Red duction (%) Primary end point Stroke MI All cause mortality CHF hospitalization Effect of prompt / better BP control within first 6 months of treatment on cardiovascular outcomes (SBP < 14mmHg) (Value Clinical Trial) BP Reduction All classes of antihypertensive agents Cardiovascular Protection Calcium channel antagonists Angiotensin converting enzyme inhibitors Angiotensin receptor antagonists 11

12 BP Reduction All classes of antihypertensive agents Cardiovascular Protection Calcium channel antagonists Angiotensin converting enzyme inhibitors Angiotensin receptor antagonists Renoprotection Angiotensin converting enzyme inhibitors Angiotensin receptor antagonists Antihypertensive Therapy Effective BP Reduction Prevention Regression Target Organ Damage Management Associated Clinical Conditions Control CV Risk Factors Prevention New Onset Diabetes 12